For patients with fatty liver disease, the established first step is FIB-4, calculated from age, AST, ALT and platelets. A score below 1.3 makes advanced fibrosis unlikely and supports primary care follow-up; in people over 65 a higher cut-off of 2.0 is often used. Higher scores should go on to vibration-controlled transient elastography or an enhanced liver fibrosis test.
Liver stiffness below about 8 kPa makes advanced fibrosis unlikely; values above about 12 kPa suggest it. Results in between, or discordant with the clinical picture, are where specialist review and occasionally biopsy come in.
- Calculate FIB-4 for every patient with steatotic liver disease and metabolic risk factors
- Use elastography when FIB-4 is 1.3 or above
- Refer when stiffness is about 12 kPa or more, or results are indeterminate
- Repeat non-invasive testing every one to three years depending on risk
Why it matters
It identifies the minority with significant fibrosis who might be candidates for MASH treatment.
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